Insurance is an ongoing nightmare for practically everyone. If you need more triptans (a common type of migraine abortive) a month than your plan allows, you’re in for a real hassle. Without insurance they are, of course, mighty pricey.
Kathy, a reader, is faced with a new bureaucratic hurdle that I’ve never seen before. Her story follows. She’d appreciate any advice you can give.
I just had to share this with someone that could understand, and maybe you have some suggestions as to whether anything can be done. I was just informed by my insurance company that I can now only get 4 Maxalt tablets at a time. I can get 8 per month (down from the 9 per month it used to be) but I have to go in to the pharmacy TWICE per month. Maxalt is the least troublesome of the triptans for me and enables me to keep working with a migraine. My migraines usually last 3 days (requiring 6 Maxalt) and CAN last 5 – 6
days. It is so infuriating that an insurance company can do this.Their explanation was that studies have shown that most people (?) only refill their prescription of 9 tablets once every 3 months. 38% of the prescriptions are never refilled. So they decided that 3 pills is a 30 day supply. Have you ever heard of anyone being successful in fighting something like this? Any ideas on what to do?
Even if you don’t have suggestions for Kathy, eave a comment with your story — whether good or bad — about getting the meds you need. I and other readers will certainly benefit from your experience.
My migraines are from having epilepsy! I called the pharmacy today to ask about maxalt and the pragmatist told me that my insurance doesn’t cover it. I asked how much the out of pocket was and he told me that it was too much and I didn’t even want to know… Did I ask him he though I could afford it? No… I asked how much, I really need this, I hurt, I can’t sleep sometimes, throbbing, tell me… Then he hurries me off the phone. Very very rude and… I feel, all because of the KIND of insurance I have.
As of 10/15/2010, the FDA has approved Botox for the treatment of migraine. If your insurance does not cover this treament, please write to them and ask them to appeal their decision and update their policy. The more appeals they receive,the louder our voice and the sooner we’ll see this treatment covered.
For those interested in trying Botox. I am 61 yrs. old w/a severe history of migraines since age 7. I tried Botox from 2003-2005 and it worked! I started w/every 3 months and eventually it worked up to 6 months at a time. I told my daughter (now 40) who has also suffered w/migraines since a child and she now does botox too. It is so great not getting headaches all the time. Downfall: I had to stop using it because I couldn’t afford it. I tried to get my insurance to pay for it because it’s less expensive than the meds (12 imitrex injections every 3 months and 27 Maxalt every 3 months). They refused, so I’m back to the meds. Now I’m about to lose my insurance. That’s how I ended up on this site. I’m looking for insurance to cover migraine costs.
Two things—
1) It’s my understanding that *any* triptain should not be taken more than 3 days in a 7 day period (and not at that frequency every week).
That aside, I know that 3 says can equal 6 pills alone; which brings me to my second point…
2) The work-around the insurance SNAFU is to get prescriptins for several different triptains at once.
That way, you may run out of Maxalt, but you still have, say, Relpax on hand.
Ask your doctor what the strongest dose is available per pill and get the RX written for that. Most of my doctors were happy to help, especially when I’ve explained the insurance limit. Then if your required dose is less, you can cut the pills in half. Insurance companies limit by pill count, not mg. At least this way you can make the most of what insurance does pay for.
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Good idea. Not all pills can be split though. I assume a doctor wouldn’t prescribe one that couldn’t, but it might be good to check with the pharmacist.
Kerrie
Wow, thanks for all the great information. I’m going to have to compile it into a post so no one misses all your suggestions.
Kerrie
I have struggled with this very problem- much too frequently. My mother is also very familiar with the insurance routine. One time we figured out that between the two of us, we had spent in excess of 6 hours on the phone in one day, speaking to various employees of the insurance company.
The best solution we have found is to continue asking insurance employees if we could please speak to their boss. Eventually we found out the name and title of the man who is in charge of decisions regarding prescriptions. We contacted his office to find out how to obtain permission for more than the “typical” prescription of the triptans that we use. We keep a formal request letter on our computer to print for our doctors to sign and send to the insurance company.
One important thing we noticed was that every six months the insurance company would “lose” the letters our doctors had sent. So now we keep it marked on the calendar to have our doctors sign a new request letter every six months and we sent it directly to the office of the prescription-authorizer.
P.S. This is a very specific example, I know, but I hope it is encouraging. Sometimes we send this official “prescription authorizer” person homemade cookies or bread to try to stay on his good side!
Suggestion #1: For the Maxalt issue–request a prior authorization. Obviously, you are not the “average” person. For averages to exist, on a mathematical basis, there have to be outliers on either side. You are one of them. (Of course, try explaining that to someone at an insurance company! They only want to insure the “middle”.) Anyway, your physician can fill out a prior authorization request to exclude you from silly rules like that, based on the fact that you don’t fit the “average”.
Suggestion #2: For the Botox issue–sometimes you can get Botox authorized through your insurance, depending on the insurance, your particular plan, what your headache diagnosis is, how well-documented your symptoms are, and how many medications and other treatment strategies you have tried. It is always worth a try, but you may have to jump through a lot of hoops. A lot, including, but not limited to, a prior authorization, and, most likely, a denial, followed by an appeal with a letter of medical necessity from your doctor. (Or, how I spend my “spare time”. Hah!)
Suggestion #3: When all else fails, and it often does, remember–you are the one who has a contract with the insurance company, not your doctor. They can only go so far in fighting for you. At some point you have to advocate for yourself. And PLEASE DO. Nothing will change until we as consumers fight back. Call. Write letters. See if your state government has a medical ombudsman’s office. If you write a letter to your insurance company, copy it to your state’s insurance commissioner. Our health care system is broken, and we need to be active advocates in doing what we can to fix it.
Unfortunately, I deal with the same thing. I can get just two (yes, two) Imitrex injections a month through my insurance. This is beyond inadequate for my needs, even considering the need to avoid medication overuse headache.
This About.com article has some helpful advice for fighting your insurance company on these limits:
http://headaches.about.com/cs/advocacy/a/trip_limits.htm
Well, I am not fighting over rescue meds, but I am fighting my insurance company over Botox. I have tried pretty much everything else and my new headache specialist thinks the Botox might be the one thing that could help my CDH. However, insurance won’t cover it and it is sooo expensive! I might be able to pay out of pocket once, but if it works I have to get it re-done every 3 months and I can’t afford that! I know its not FDA approved for migraine yet, but there are so many studies showing it can work, and it would save them money in the long-run if I could get off all the other meds they do pay for!
Jamie
I am constantly arguing with my insurance company. Your first step should be to ask your doctor to call the insurance company and explain why this limit needs to be raised in your individual case. This might work, at least for a short time. Your doc might also have samples of Maxalt to help you get through the month. Good luck!